Patient Records Release Form

Please complete the form below to request Stratford Medical Centre send your records to your new GP.

    Patient Details

    Patient Name:
    Date of Birth:
    Address
    Phone:

    New Doctor/Practice:

    New Doctor/Practice Name:
    Address:
    Phone:
    Fax:

    Please send the following information to my new GP:
    If "Other" selected above, please list the specific information you are requesting:

    Date:
    Signature: